Dr. Prakash Budhathoky

It's been now sixteen months since COVID-19 was first detected in Wuhan, China. We have come a long way since its outbreak and the knowledge and experience gained over time have certainly helped better manage the patients with coronavirus symptoms.
Timely diagnosis and treatment give the patient the best chance to recover from COVID-19. It is important to carefully elicit the medical history. Otherwise, important health cues can be missed and the disease may be misdiagnosed, which may prove costly for the patient. It is crucial to know what should be done and what should not in the given clinical situation. Here are a few dos and don'ts concerning the diagnosis and management of COVID-19.

Ignoring Atypical Symptoms
The symptoms of COVID-19 are no longer limited to the respiratory system (dry cough, fever, and difficulty in breathing). Many extra-pulmonary symptoms of COVID-19 have now been reported. These may differ even in different members of the same family.
Several atypical symptoms of COVID-19 have been reported. These include nausea/vomiting, diarrhoea, headache, increased frequency of urination, right abdominal pain, sudden loss of taste and/or smell (bitter and sour tastes are retained), skin lesions (rash, vesicles), conjunctivitis, COVID-toes (presenting as gout-like symptoms), hiccups, calf pain, tiredness, malaise, dizziness, etc. Such unusual symptoms of COVID-19 are likely to be missed. Do think of COVID-19 in these times and get the patient tested.

COVID-19 In Isolated Diarrhea
Diarrhoea may sometimes be the only symptom of COVID-19. Later on fever, the cough may or may not develop. Acute diarrhoea in COVID-19 is always small intestinal diarrhoea. It is painless, there is no blood or mucous in stool. The virus may remain in the stool for up to 3 months. A patient who has diarrhoea may be a superspreader, i.e., he can spread the infection to other members of the family. If a patient presents with new-onset, intermittent diarrhoea for 48 hours duration, do have a high index of suspicion for COVID-19.

Fever After Exertion
Fever of COVID-19 is typically low grade (<100.40F) and occurs after exertion. The fever is inflammatory and not due to the viral infection. It does not respond to paracetamol, instead, the fever responds to anti-inflammatory drugs like mefenamic acid, naproxen, nimesulide and indomethacin. Do not miss the first time detection following low-grade fever after exertion. This may often be the first symptom of COVID-19.

Missing Day 1
A person can test positive for COVID-19 even when there is a single symptom. This can be single loose motion, headache, loss of smell, calf pain, isolated skin rash and any other non-specific symptom as discussed above. Other symptoms may appear after 48-72 hours.
If you have been exposed to COVID-19, the first symptom is most important. Do not ignore any symptom, which cannot be explained. This is Day 1 of the illness; the test may or may not be positive. Day 1 is important as pneumonia usually will develop around Day 3 of the infection.

Ignoring Days 3-6 of Illness
Critical days are Day 3-6 after the first symptom or positive test, whichever is earlier. The patient may develop pneumonia around the third day of the illness, although not every patient develops pneumonia. Look for fall in SpO2 on 6MWT by 4 (hypoxia; this may be a sign of micro-or macrovascular emboli) or development of exertional tachycardia or difficulty in talking or cough; these are suggestive of pneumonia. If undetected and untreated, complications may set in after Day 5. If the patient is given a steroid, antiviral at the onset of pneumonia (Day 3), mortality should be an exception and not a rule.

Not Recognizing Red Flags
Not taking due precautions for any comorbid condition, fall in SpO2 or development of shortness of breath or cough on 6MWT, CRP >26, absent eosinophils and absolute lymphocyte count <1000 on CBC are red flag signs of COVID-19. Do baseline CBC, ESR, CRP, CRT, ferritin and/or D-dimer. Repeat ESR, CBC and CRP daily. Do not ignore isolated lymphopenia and eosinopenia on Day 1 of the illness. These may sometimes predate inflammation and may be a sign of oncoming inflammation.

Treating Report, Not Patients
The RT PCR test using throat/nasal swab is the gold standard test for the diagnosis of COVID-19. But it has a sensitivity of around 67%. This means that about 33% of the results may be false negative. If the patient has classical symptoms of COVID-19 and the report is negative, repeat the test.
A CT scan or chest X-ray can be done on Day 1 itself. If you suspect that the patient has COVID-19, don't wait for confirmation. You may miss Day 3 of the illness, so then you will miss pneumonia, happy hypoxia.
Isolate the patient and start treatment. Rapid antigen tests may also give false-negative results. Therefore, always interpret the test results with the clinical presentation of the patient.

Mistaking COVID-19 As Typhoid
Typhoid antigen test can give a false-positive result in COVID-19. Patient with COVID-19 can have fever and diarrhoea. If you miss COVID-19, thinking it to be a case of typhoid fever, this can be dangerous for the patient. If you miss COVID-19, you will miss pneumonia on Day 3-6 and complications can develop, which may be irretrievable at times. If you suspect that the patient has typhoid, do not do a Typhidot or Widal test. Instead, send a blood culture. Unless the blood culture is positive, do not treat these patients for typhoid.
Gargling Reduces Virus Load
Evidence has shown that the virus is present in high quantities in the throat, making it a major reservoir of the virus, not only for the symptomatic patients but also the asymptomatic ones. Although gargling will not eliminate the virus, it may reduce the viral load in the throat thereby reducing the risk of transmission. Gargling with an oral antiseptic such as povidone-iodine along with the use of facemasks and hand washing may be advised as a preventive measure against the virus.

Test, Trace, Contain
In April, Health Ministry officialsestimated Covid-19 infections to surge within 3 to 4 weeks. While the epidemiological model used by the ministry is unclear and off the public domain. The University of Oxford has also developed the SEIR (susceptible-exposed-infectious-recovered) model to estimate the trajectory of Covid-19 and analysed the impact of three disruption strategies—low, medium and high.
Still, we cannot afford to let this window of opportunity slip by. To break the chain of transmission, the mantra remains the same- Test, Trace and Contain. The 4-month long lockdown pushed the country to the brink of chaos, manifesting in physical, psychological and economic consequences for the masses. With next to nothing to cushion the social and economic impacts of disruption, the government has also done little to prepare and upgrade its healthcare capacity as the number of patients in need of ICU beds and ventilators increases. The government should not repeat the same errors over and over again.

( Dr. Budhathoky is a central Treasurer Of Nepal Medical Association)